HA Final Exam

Passive Range of Motion (PROM)

• PROM is performed by nurses when patients are unable to move their joints independently.

• It helps to maintain flexibility and prevent contractures.

• IMPORTANT: Do not force movements beyond comfortable limits.

• Neck PROM:

  • Movements include:

  • Flexion

  • Extension

  • Hyperextension

  • Lateral bending

  • Rotation

  • Caution: Do not hyperextend in older adults.

• Shoulders PROM:

  • Movements include:

  • Flexion

  • Extension

  • Hyperextension

  • Abduction

  • Adduction

  • Internal and external rotation

  • Circumduction

  • Always compare bilaterally for assessment.

• Elbows PROM:

  • Movements:

  • Flexion

  • Extension

  • Note: Pain may indicate epicondylitis.

• Forearm PROM:

  • Movements:

  • Pronation

  • Supination

• Wrist PROM:

  • Movements include:

  • Flexion

  • Extension

  • Hyperextension

  • Radial and ulnar deviation

  • Assessment: Also check grip strength.

• Fingers PROM:

  • Movements include:

  • Flexion

  • Extension

  • Hyperextension

  • Abduction

  • Adduction

• Thumb PROM:

  • Movements include:

  • Flexion

  • Extension

  • Abduction

  • Adduction

  • Opposition

• Hips PROM:

  • Movements include:

  • Flexion

  • Extension

  • Hyperextension

  • Abduction

  • Adduction

  • Internal and external rotation

  • Caution: Older adults may experience decreased range of motion.

• Knees PROM:

  • Movements:

  • Flexion

  • Extension

  • Compare both sides for assessment.

• Ankles PROM:

  • Movements include:

  • Dorsiflexion

  • Plantarflexion

  • Inversion

  • Eversion

  • Consideration: Check for fall risk in elderly patients.

• Toes PROM:

  • Movements include:

  • Flexion

  • Extension

  • Abduction

  • Adduction

• Spine PROM:

  • Movements include:

  • Flexion

  • Extension

  • Lateral bending

  • Rotation

  • IMPORTANT: Do not perform if a spinal injury is suspected.

Significant Neurological Changes

• Signs of alerting neurological issues:

  • Sudden confusion

  • Agitation

  • Decreased level of consciousness (LOC)

  • Seizures

  • Abnormal posturing (decorticate or decerebrate)

  • Changes in pupil size

  • Abnormal eye deviation

  • New onset weakness or paralysis

  • Sensory loss

  • Dangerous vital sign changes

  • Arrhythmias

  • Fever

  • Cushing's response characterized by hypertension, bradycardia, and irregular respirations

  • Irregular breathing patterns

Normal Neurologic Findings

1. Alertness and orientation to person, place, and time.

2. Clear and appropriate speech.

3. Intact cranial nerves II-XII.

4. Purposeful movement of all extremities equally.

5. Sensation intact to light touch.

6. Reflexes are 2+ (normal).

7. Steady gait and coordinated movements.

8. Pupils are equal, round, and reactive to light (PERRLA).

Glasgow Coma Scale (GCS)

• The GCS assesses a patient's response to stimuli and is utilized in cases of head injury, stroke, and coma assessments.

• Score Range: 3 (deep coma) to 15 (normal).

• Total score interpretation:

  • 14–15 = Normal/Baseline

  • 9–13 = Moderate brain injury

  • ≤ 8 = Coma, at risk for airway obstruction

Eye Response (1-4)

• 4 = Spontaneous

• 3 = To voice

• 2 = To pain

• 1 = None

Verbal Response (1-5)

• 5 = Oriented

• 4 = Confused

• 3 = Inappropriate words

• 2 = Incomprehensible sounds

• 1 = None

Motor Response (1-6)

• 6 = Follows commands

• 5 = Localizes pain

• 4 = Withdraws from pain

• 3 = Flexion (decorticate posture)

• 2 = Extension (decerebrate posture)

• 1 = No movement

Mini-Mental Status Exam Categories

1. Orientation to time

2. Orientation to place

3. Registration of words

4. Attention/calculation (using serial 7s or spelling the word "WORLD" backward)

5. Recall

6. Language/identification; repetition

7. Completing a 3-step command or drawing

Cultural Variations & Health Disparities

• Culture influences communication styles, pain expression, concepts of touch, and decision-making processes.

• Health disparities may stem from socioeconomic status, access to healthcare, race, and ethnicity.

• Recommendations:

  • Use interpreters where necessary

  • Respect cultural beliefs

  • Acknowledge and avoid personal biases

Older Adult Neurological Considerations

• Neurological changes in older adults may include:

  • Slower reflexes

  • Decreased sensation

  • Presbyopia (age-related vision changes)

  • Presbycusis (age-related hearing changes)

  • Slower motor response

  • Increased fall risk

  • Potential memory changes

  • Concerns regarding polypharmacy (use of multiple medications).

Assessing the Unconscious Patient

• Initial assessments should focus on the ABCs:

  • Airway

  • Breathing

  • Circulation

• Follow with evaluations such as:

  • Using the GCS

  • Evaluating pupils

  • Testing the patient’s response to voice or pain

  • Observing motor response

  • Checking for posturing

  • Assessing for signs of trauma or checking for medical alert bracelets

  • Monitoring vital signs and breathing patterns

Meningeal Signs (used for diagnosing meningitis)

• Nuchal Rigidity: Neck stiffness indicating meningeal irritation.

• Brudzinski’s Sign: Flexion of the neck leads to involuntary hip and knee flexion.

• Kernig’s Sign: Pain occurs upon extending the leg while the hip is flexed.

Tanner Staging for Male Development

Stages include:

1. Stage 1: Prepubertal

2. Stage 2: Testes enlarge, sparse pubic hair appears.

3. Stage 3: Penis increases in length; darker hair begins.

4. Stage 4: Penis widens, adult-like hair appears (not on thighs).

5. Stage 5: Adult genitalia, pubic hair extends onto thighs.

Testicular Torsion

• This condition is an emergency characterized by:

  • Sudden severe unilateral testicular pain

  • Nausea

  • A high-riding testicle

  • Absent cremasteric reflex

• Immediate surgical intervention is crucial and should occur within 6 hours of symptom onset.

Epididymitis

• Symptoms include gradual onset of pain, swelling, and tenderness of the epididymis, with possible fever.

• Pain relief may be achieved through elevation (positive Prehn sign).

• Causes often include:

  • STIs in younger men

  • E. coli infections in older men

Prostate Cancer Screening

• Screening recommendations:

  • Begin at age 50 for those at average risk.

  • For high-risk individuals, such as African Americans or men with a family history, begin at age 45.

• Tests include:

  • Prostate-Specific Antigen (PSA) blood test

  • Optional Digital Rectal Exam (DRE)

• Shared decision-making is advised with the patient regarding screening options.

Symptoms of Late-Stage Prostate Cancer

• Urinary complications:

  • Urinary hesitancy

  • Weak stream

  • Hematuria

• Other associated symptoms:

  • Back pain indicative of bone metastasis

Common Male Genitourinary Symptoms

• Patients may report symptoms including:

  • Dysuria (painful urination)

  • Hematuria (blood in urine)

  • Frequency and urgency of urination

  • Nocturia (waking up at night to urinate)

  • Urinary retention

  • Penile discharge

  • Scrotal pain or swelling

  • Erectile dysfunction

Differential Diagnosis for GU Symptoms

• Dysuria:

  • Possible causes: UTI, STI, prostatitis

• Hematuria:

  • Possible causes: Kidney stones, UTI, cancer, trauma

• Scrotal Pain:

  • Possible causes: Testicular torsion, epididymitis, hydrocele, hernia

• Frequency/Nocturia:

  • Possible causes: Benign Prostatic Hyperplasia (BPH), diabetes, UTI

• Discharge:

  • Possible causes: Gonorrhea, chlamydia

Tanner Staging for Female Development

Pubic Hair Staging:

1. Stage 1: No hair

2. Stage 2: Sparse/light hair present on the labia

3. Stage 3: Darker, coarser hair that begins to spread

4. Stage 4: Adult-like hair that does not extend to thighs.

5. Stage 5: Adult pattern that extends to thighs.

Menopause

• Defined as 12 consecutive months without menstruation.

• Typical onset age: 50-52 years, with perimenopause beginning around age 40.

• Common symptoms include:

  • Hot flashes

  • Night sweats

  • Insomnia

  • Vaginal dryness

  • Mood changes

• Associated health risks involve heart disease and osteoporosis.

• Recommendations include increased calcium, vitamin D intake, and regular exercise.

Pregnancy Trimesters

First Trimester (0-12 weeks):

• Symptoms include nausea/vomiting, fatigue, and organ formation.

• Important: Avoid teratogens and ensure adequate folic acid intake.

Second Trimester (13-26 weeks):

• Notable for fetal movement, completion of anatomy scan, and screening for gestational diabetes.

Third Trimester (27-40 weeks):

• Rapid fetal growth occurs, with common complaints including shortness of breath (SOB), back pain, and edema.

• Birth planning and discussions on breastfeeding education should be conducted.

Determining Gestation

• Naegele’s Rule:

  • Calculation: LMP (Last Menstrual Period) + 7 days - 3 months

• Confirmation should be done using ultrasound and fundal height measurements, especially after 20 weeks.

Newborn & Infant Growth Parameters

• Birth weight should double by 6 months and triple by 1 year.

• Length increases by 50% by the first year.

• Fontanel Closure:

  • Posterior fontanel: closes by 2 months

  • Anterior fontanel: closes between 12-18 months.

• Average newborn weight: 2500-4000g

• At birth, head circumference is greater than chest circumference.

Safe Sleep Habits for Infants

• Recommendations include:

  • Place infants on their backs to sleep.

  • Use a firm mattress with no pillows or blankets.

  • Avoid co-sleeping and overheating the sleeping area.

  • Room-sharing is encouraged for safety.

Choking Prevention Strategies

• Avoid feeding infants and toddlers foods that pose a choking risk, including hot dogs, grapes, popcorn, and nuts.

• Always cut food into small pieces and supervise children during meals.

Language Development Milestones

• At 1 year: a few words

• At 2 years: can make 2-word phrases and can say 50+ words

• At 3 years: can form 3-word sentences, with 75% of speech understandable

• At 4 years: able to tell stories and their speech is 100% understandable

• During adolescence: capacity for abstract thinking and complex communication development.

Vital Signs Across the Lifespan

Newborn:

• Heart Rate (HR): 110–160

• Respiratory Rate (RR): 30–60

• Blood Pressure (BP): 60–80 mmHg / 40–50 mmHg

Infant:

• HR: 90–140

• RR: 24–38

• BP: ~85/50 mmHg

Child (Ages 1-12):

• HR: 80–120

• RR: 20–28

• BP: 90–110 mmHg / 55–75 mmHg

Adolescent (Ages 12-18):

• HR: 60–100

• RR: 12–20

• BP: 100–120 mmHg / 65–80 mmHg

Adult:

• HR: 60–100

• RR: 12–20

• BP: <120/80 mmHg

Abnormal Vital Signs by Age Group

• Newborn:

  • HR <110 or >160

  • RR <30 or >60

  • BP <60/40 or >80/50

  • Temperature <97.7°F or >100.4°F

  • SpO₂ <95% (considered red flag)

• Infant:

  • HR <90 or >160

  • RR <24 or >40

  • BP <80/45 or >100/70

  • Temperature <97.7°F or >100.4°F

  • SpO₂ <95% (concerning)

• Child (School-Age):

  • HR <70 or >130

  • RR <18 or >30

  • BP <90/55 or >120/80

  • Temperature >100.4°F or <97°F

  • SpO₂ <95%

• Adolescent:

  • HR <50 or >120

  • RR <12 or >24

  • BP <90/60 or >130/85

  • Temperature >100.4°F or <97°F

  • SpO₂ <95%

• Adult:

  • HR <50 or >110

  • RR <12 or >24

  • BP <90 systolic (indicates hypotension)

  • BP >130/80 (indicates hypertension)

  • Temperature >100.4°F or <95°F

  • SpO₂ <94% (needs evaluation)

  • SpO₂ <90% (critical condition)

RED FLAGS Across All Ages

• Vital Signs:

  • RR >30 or <10

  • HR >130 or <40

  • SpO₂ <90%

  • Temperature >104°F

  • BP <90 systolic with accompanying symptoms such as dizziness or confusion

STI Incidence (Chapter 24)

• Approximately 26 million new STIs are identified each year, with half of these occurring in individuals aged 15-24.

Complications of STIs (Chapter 24)

• Complications can lead to conditions such as cervical cancer, infertility, pelvic inflammatory disease, and chronic pelvic pain.

Importance of Confidentiality in Sexual History (Chapter 24)

• Maintaining confidentiality promotes honest disclosure and enhances the quality of STI preventive education.

Healthy People 2030 Reproductive Health Goals (Chapter 24)

• Aims to reduce the incidence of syphilis, congenital syphilis, pelvic inflammatory disease, genital herpes, HPV infections, and parent-to-child HIV transmission.

• Goals also include increasing chlamydia screening rates.

Key Health Promotion Topics in Women’s Reproductive Health (Chapter 24)

• Topics include:

  • Menopause education

  • HPV prevention initiatives

  • Cancer prevention education

  • STI prevention approaches

  • Guidance on performing genital self-exams

  • Education on female genital cutting concerns

Screening for High-Risk Adults (Chapter 24)

• Recommendations:

  • Screen adults with multiple partners or those who use IV drugs for:

  • Chlamydia

  • Gonorrhea

  • HIV

  • Hepatitis B

  • Syphilis

STI Prevention Messaging (Chapter 24)

• Promotes:

  • Monogamous relationships

  • Abstinence

  • Consistent condom use to lower risk for STIs and HPV.

Contraceptives & STIs (Chapter 24)

• Contraceptives such as oral contraceptive pills (OCPs), long-acting reversible contraceptives (LARCs), and sterilization do not provide protection against STIs.

• Only condoms have been shown to reduce STI transmission effectively.

Cervical Cancer Primary Risk Factors (Chapter 24)

• HPV infection is recognized as the principal risk factor associated with cervical cancer.

• Other risk factors include:

  • Smoking

  • HIV infection

  • Chlamydia infection

  • Poor dietary habits

  • Low income

  • Family history of cervical cancer.

Cervical Cancer Symptoms (Chapter 24)

• Early stages are typically asymptomatic, while advanced stages may present with symptoms such as:

  • Abnormal bleeding, particularly after intercourse.

Cervical Cancer Screening Recommendations (Chapter 24)

• Ages 21-29: Pap smear every 3 years (cytology only).

• Ages 30–65: Pap every 3 years OR Pap plus HPV cotest every 5 years.

• ACS Screening Recommendations:

  • The American Cancer Society (ACS) recommends initiating screening at age 25 with primary HPV testing; ACOG has not yet adopted this practice.

Ovarian Cancer Screening Recommendations (Chapter 24)

• Routine screening for ovarian cancer is not recommended.

Bright Futures Program (Chapter 27)

• This is an evidence-based program by the American Academy of Pediatrics (AAP) aimed at promoting pediatric health and preventing diseases.

Bright Futures Focus (Chapter 27)

• The program supports child health within various environments, including family, school, community, and healthcare systems.

Pediatric Assessment Considerations (Chapter 27)

• Assessments should take into account:

  • Social determinants of health.

  • Environmental exposures.

  • Community support systems.

  • School environment factors.

Health Promotion Priorities for Youth (Chapter 27)

• Priorities include:

  • Promotion of healthy nutrition practices

  • Encouragement of physical activity

  • Substance abuse prevention initiatives

  • Dental care access

  • Mental health facilities availability.

Assessing School Performance (Chapter 27)

• Emphasis should be placed on evaluating:

  • Literacy levels

  • Language skills

  • Academic progress

  • Individual goals and aspirations.

Developmental & School Readiness Goals (Chapter 27)

• Goals should focus on increasing developmental screenings and supporting readiness for school and academic completion.

Obesity Prevention Goals (Chapter 27)

• Strategies include:

  • Reducing consumption of sugary and fatty foods.

  • Improving the quality of school meals.

  • Promoting daily physical activity among youth.

Physical Activity Promotion (Chapter 27)

• Initiatives aim to increase activity levels in schools and encourage participation in organized sports or movement programs.

Substance-Use Prevention (Chapter 27)

• Preventive strategies targeting early tobacco, vaping, alcohol, and drug use.

Mental Health Promotion (Chapter 27)

• Focus on improving access to mental health services, including implementation of school-based counseling programs.

Dental Health Promotion (Chapter 27)

• Encourage regular dental visitations and the practice of daily oral hygiene.

Sleep Promotion (Chapter 27)

• Educate on establishing consistent sleep routines and ensuring adequate sleep duration appropriate for different age groups.

Essential Pediatric Teaching Topics (Chapter 27)

• Important topics include:

  • Immunizations

  • Sleep hygiene

  • Limitations on technology and screen time

  • Car safety practices

  • Safety measures regarding poisons, fire, water, and outdoor activities

  • Obesity prevention strategies

  • Contraception education and STI prevention education.